creation date: 2026-09-07 17:52
tags: Pathologies
Status Epilepticus
Background
Definitions
Status epilepticus is a neurological emergency.
Convulsive status epilepticus: generalized tonic-clonic movements and mental status impairment
Non-convulsive status epilepticus: seizure activity by EEG with no accompanying tonic-clonic movements
Convulsive status epilepticus has an annual incidence of ~50 episodes/100,000 children and is highest in children younger than 2.
Etiology
Acute pathology
- Acute CNS infection (meningitis or encephalitis)
- Anoxic injury
- Metabolic derangement (hypo/hyperglycemia, hyponatremia, hypocalcemia)
- Traumatic injury
- Drug-related
- Antiepileptic drug non-compliance or withdrawal
- Antiepileptic drug overdose
- Non-antiepileptic drug overdose
- Prolonged febrile convulsion
Remote pathology
- Cerebral dysgenesis
- Perinatal hypoxic-ischemic encephalopathy
- Progressive neurodegenerative disorders
- Prior brain injury
Risk Factors
Clinical Presentation
Signs & Symptoms
History & Physical Exam
A brief history should include:
- History of seizure disorder
- Other symptoms (eg. fever)
- Medication usage
- Allergies to medication
Diagnosis
Criteria
Diagnosis is made clinically or with EEG.
Convulsive status epilepticus
- Continuous generalized tonic-clonic seizure activity with loss of consciousness longer than 30 minutes OR
- Two or more discrete seizures without a return to baseline mental status
Work-up
Initial assessment
The following should be ordered immediately:
- POCT glucose
Evaluation of etiology
Etiology should be determined once the patient has been stabilized. In cases of prolonged febrile seizure of known seizure disorder, significant workup is likely unnecessary.
If the etiology is unclear, consider the following:
- Electrolytes
- Serum glucose
- CBC and differential
- Cultures (if sepsis suspected)
- Blood gas
- Anticonvulsant levels (if on long-term therapy)
- Urine and blood toxicology
More workup may include:
- Serum calcium
- Blood urea nitrogen
- Magnesium
- Liver function tests
- Lactate
- Ammonia
A lumbar puncture should be deferred until vitals are stables and there is no suspicion of increased ICP, and convulsions have stopped.
Differential
Red Flags / Complications
Management
Acute Management
Maintain ABCs
- Suction
- Chin lift / jaw thrust
- 100% oxygen by face mask if needed
- Consider assisted ventilation if signs of respiratory depression or oxygen saturations remain low despite supplemental oxygen
Monitor vitals continuously and obtain two large-bore IV as soon as possible.
Terminate seizure
Use of medication for terminating seizure should be considered if seizure last longer than 5-10 minutes.
First line consist of benzodiazepines:
- Lorazepam IV
- Midazolam IV or IM
Second line options if refractory to benzodiazepines:
- Fosphenytoin/phenytoin
- Phenobarbital
The obtained bedside glucose test will determine if dextrose is needed. If BG ≤2.6 mmol/L: bolus 0.5 g/kg dextrose via 2 mL/kg D25W (central line) or 5 mL/kg D10W (peripheral IV). Recheck BG q3-5 min and repeat bolus as needed.
Refractory cases
If first and second line options do not stop seizure, consult pediatric ICU and neurology.